Hollyhurst Medical Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At our previous inspection in September 2022 the practice was rated Good at providing safe services. At this assessment we have rated the practice as requires improvement for providing a safe service. We assessed a total of 5 quality statements out of the maximum 8 from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection. There was a breach of regulation as we were concerned about the safety of the environment at the Elvaston Road Surgery from both a fire risk and infection prevention and control viewpoint. The providers systems and processes in place had failed to identify these and resolve issues as they arise. There was also no record of regular clinical supervision for locum and salaried GP’s and other clinical staff. Recruitment checks for staff were in place together with mandatory training but staff vaccination records were not held in line with regulations. However, we found staff took all concerns seriously. When things went wrong, staff acted to ensure people remained safe. Managers investigated all reported incidents to reduce the likelihood of them happening again. We undertook clinical searches on the practices clinical system, which were mostly positive. Since the inspection some works were scheduled to improve the environment at Elvaston Road Surgery.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

In the recent GP national survey, carried out between January and March 2024, patients described their overall experience of the practice as good. The practice also had a monthly survey for a proportion of patients to complete to enhance regular feedback to help improve the service. We received no specific feedback directly from patients in this area.

Staff and leaders told us they engaged and listened to patients. Managers told us they used incidents and complaints to improve systems and processes. Staff knew how to report incidents and significant events and said the findings were shared although some staff did not attend meetings where these were discussed. Some staff said they were aware of complaints raised and none of the 13 staff asked had been involved in an investigation. Most staff did not know where patients could find information to complain. Most staff told us patients could find information about how to complain on the website however we couldn't find any details on the Hollyhurst Medical Centre website.

The provider had a system to record significant events and complaints. We saw records to support this, and when things went wrong staff apologised and gave people support in a timely manner. There was evidence to show that the practice was learning from and acting upon the information they found, which resulted in changes to improve care. We saw 3 examples of minutes of clinical staff meetings where significant events and complaints were discussed, and 2 examples of nonclinical staff meetings where significant events and complaints were an agenda item, but none were recorded as discussed.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff and leaders at the practice told us there were issues at their Elvaston Road surgery in terms of infection prevention control and health and safety. The infection prevention and control issue was noted in the business plan as a medium term goal to be upgraded and redecorated in the next 0 – 2 years. The fire safety issues were identified by the Fire service audit and at the time of inspection leaders told us they were getting quotes for the works in the first instance.

We visited the Elvaston Road surgery. Audits had already identified refurbishment and other improvements were needed to ensure the building met health and safety and infection prevention and control standards. The provider had been issued with a schedule of works by the Tyne and Wear Fire and Rescue Service chief fire officer on 13 May 2024, as the premises were non complaint in The Regulatory Reform (Fire Safety) Order 2005. The report stated that there were several deficiencies noted at Elvaston Road surgery. These included issues with the fire alarms, fire evacuation routes, lack of fire risk assessments and maintenance of fire safety equipment including emergency lighting. They also noted structural issues such as holes in fire doors and a broken door seal. The provider had been served with a fire safety order to ensure compliance with legislation. We noted fire evacuation routes remained obstructed at the time of our visit by sets of fixed shelves that narrowed access via a doorway which led from the reception office area to the nearest safe exit. We carried out a walk around of Hollyhurst Medical Centre on our site visit and saw the environment was satisfactorily maintained, for example, the emergency equipment, medication, appropriate calibration of equipment and portable appliance testing (PAT). The practice was clean, and we saw the completed cleaning schedules. During our visit to Elvaston Road surgery we noted it was tidy, and the equipment was satisfactorily maintained and dated where appropriate. However, we found black mould in a toilet around 5 meters away from one of the nurse treatment rooms handwashing facility which had failed to be identified and removed.

We found the provider had failed to carry out regular fire risk assessments as part of their oversight of the environment. Elvaston Road surgery had recently had a Fire service inspection with several issues including the lack of a fire risk assessment highlighted. We requested and were provided with a schedule of works which indicated what work was outstanding to rectify the issues and when this work would be completed. However, not all issues noted were scheduled to be repaired or refurbished by the provider, for example the repair of several fire doors and an ineffective door smoke seal.

We received no specific feedback from patients on this.

The practice employed a mixture of clinical and non-clinical staff. There were records of staff professional registrations and mandatory training. The practice utilised long term locum staff to ensure sufficient staff cover for the practice. Leaders confirmed they set the staffing levels. Managers stated the practice was fully staffed at the time of our assessment visit. However, they went on to detail that they were both nursing and administrative hours short. There were solutions in place for this with the practice nurse increasing their hours and the upskilling of their healthcare assistant. There was some internal movement within the administrative staff that would also see an increase in administrative hours. Leaders explained that the immediate deficit was being covered by locum hours and the provider providing additional clinical support. However, staff who completed questionnaires told us there were insufficient staff both clinical and administrative to carry out their roles effectively.

We reviewed staff rotas and the number of staff in post. These showed most clinics were covered by other staff when needed such as for annual leave or sickness. Recruitment checks were carried out, DBS records were available together with staff risk assessments where appropriate. However, there was not an effective employee immunisation programme. The practice has been made aware of this and are working to resolve it. Some staff received the necessary induction and training. However, there was no induction process for locum staff who cover shifts at the practice. The practice has been made aware of this and have since implemented a process. The training matrix shared with CQC indicates compliance with mandatory training. The provider gave staff protected time and support to complete continuous professional development. Leaders share any training or policy updates via email. Audits were carried out regularly. The provider reviewed learning and development needs for clinical staff and the same was completed for non-clinical staff by leaders. The practice told us they monitored the performance of their non-medical prescribers. We reviewed an audit stating 20 consultations were checked over a 4-month period. The audit stated the practitioner was working to a high standard. However, according to the audit of the 20 patients involved 6 had not had their clinical issues correctly coded on the system; 2 had not had their history taken properly; and 6 had not had adequate safety netting. The audit stated that the practitioner was spoken to at their annual appraisal and areas of improvement identified for the coming year. This meant the provider was not responding to errors quickly enough to support the practitioner to keep patients safe. Records also showed that some staff did not have regular supervision. The practice was unable to provide any evidence of audits or measures in place for clinical supervision to ensure locum and salaried staff were operating safely.

We received no specific feedback from patients on this.

The leadership team told us they were aware there were issues at Elvaston Road surgery and that Hollyhurst practice required some refurbishment. There was some confusion amongst staff who completed our staff questionnaires as to who the infection control lead was for the provider.

At Elvaston Road surgery, we found that the clinical room used by the nurse was not fit for purpose in terms of infection prevention control. There were no hand washing facilities within the clinical room. In order to wash their hands, clinicians had to pass through 2 doors and a communal area before accessing the sink. Around 5 metres of the sink was a toilet area that was covered in a substantial amount of black mould. Black mould is a type of fungus the spores of which can be harmful and can cause people to develop respiratory issues. Black mould should be removed as quickly and safely as possible and steps should be taken to prevent it from growing back. We inspected Hollyhurst Medical Centre, and found some areas were in need of redecoration, leaders explained that resources were currently focused on the Elvaston Road surgery. We brought the lack of elbow operated taps at the main site to the Managers attention.

Infection, prevention control training had been completed by staff to a satisfactory level. Leaders had confirmed there were issues with infection prevention and control at the Elvaston Road surgery. We visited the premises and found black mould on the walls near to the handwashing area for 1 of the treatment room used by clinical staff. The systems and processes in place had failed to identify and remove this immediate risk.

Staff involved people in reviews of their medicines and helped them understand how to manage their medications safely.

Staff received regular training on medicines management, and felt confident managing the storage, administration and recording of medicines.

Staff managed medicines safely and regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, and vaccines. Staff showed how they disposed of expired or unwanted medicines that patients had returned. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. We examined medicines used for managing heart failure. We found 6 out of 24 patients on a diuretic medicine used in the management of this patient group had not had the necessary monitoring. We noted the practice did not have a robust clinical search system in use to help identify and monitor patients. We examined in detail the clinical records of 6 patients who had been prescribed methotrexate, a disease modifying antirheumatic medicine. We noted that 5 of the 6 patients had not had the administration of the medicine recorded correctly in the clinical system.

We found that the practice did not always have appropriate systems to recognise certain safety alerts as being overdue. There was also not an effective process in place for patients who declined monitoring blood tests. As a result of these points, some patients were not reviewed in a timely manner.

The searches of the clinical records we carried out helped to demonstrate that patients care, and treatment was assessed and reviewed. However, we noted that 136 patients out of a total of 329 patients with asthma did not all receive their reviews in a timely manner and had not been issued with steroid cards. This equated to 41% of asthma patients not having had the necessary review.